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Miscellaneous - 20 SAW MILL ROAD 4/30/2018 (2)
N O N p O A C/) D � o 9 OD p r- o X o v 0 E LE VAT t O N'3. M.-W-w1olan . I Z_w ► � I i � Lim AS E5UILT r� 5015-5ur-E!! E< Desr�o ,i.._. SY5-r EM 1 N3 I&O-r-r Pzc)pe-ZTIE5 FRAh1i� G��L�NAS � ASSUGIA,-T'ES n101Z. 11--) � -I- CD --I cfzq� 0 .CLJ SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978)774-2772 F 14 - SYSTEM PUMPING RECORD t COMMONWEALTH OF MASSACHUSETTS O MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: V V � � / Q cKa sewi m�I SYSTEM LOCATION: R(j I house. P I . 686-36�s I � `� h } DATE OF PUMPING:_ j / -,?,6- 9 S' QUANTITY PUMPED: GALLONS CESSPOOL: NO F-1 YES a SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: � INSPECTOR: � Y 1i1.7tl+t•••i stay t,tlril:lL Lliil 1,Uf # AF OVID i DATE DI PR TTID ) AVATIC�J Ob FpI d Ba qms t - �— - F �, irAIL OK 1. Distance Tot a. Wetlands b. Drains §: c. Well 2. Water Line Location 3- NoMPipe. %. Septic Tank - - - a.. -Tees -_Length & To Clean.Out Covers. . b. Cement Pipe to Tank — Oa Both Sides of Tank 5. Distribution Box f ✓ a. Covers do Box - No Cracks b. All Lines Flowing Equal Amounts _ 1 C. No Back Flow 6*. Leach Fiel or Trench a. Dimens' ns b. Stone th . c: Capp d Inds .. d. Cl Double Washed Stone 7. Leach Pit a. Dimes ons .- ._ b. Ston Depth c. Spl sh Pads-_ d. T - e. C t Pipe to Pit - Both Sides / f. can Doubt a Washed Stone t } 8. . No Garbage Disposal r 9. .7inal Grading Inspection . 10. Barricading Covered S.,stea As Built Submitted.. a. Lot Location - : ` b. Dimensions of System s c. Location Stith Regard_to Pere Test d. Elevations ` e: Water Table aorta Knaover,mass a • II '_'itle 9 eg 6 i SUBMFACE DISPOSAL DESI(K CHOCK LIST UMMMA I DISAPPRMM DATE Reasons s The submitted plan moat show as a minimums a) the lot to be served -area, dimensions lot #, abutters b location and log deep observation hoes -distance rB ties c location and results percolation tests -distance to ties design calculations & calculations showing e location and dimensions oP red leaching area f existing and system -including reserve area g proposed contours g) location any wet areas 1.thin loot of sewag di • disclaimer -check wetlands mapping � sposal system or (h) surface and subsurface drains within lops of sewage disposal system or disclaimer (i) location any drainage easements within 100,. of s system or disclairP� er- emge disposal (3) know sources of water. Board files . system or disclaimer sP within 200 of sewage disposal (k) location of aMT proposed well to serve lot -100 , from (1) location of water lines on property -dot from 1 hinglfacilitt. facility (m) location of benchmark ;n) driveways ,0 garbage disposals P no PVC to be used in construction �q) profile of system -elevations of basement, plumb distribution box inlets and outlets Other elevations , distributionodsePiP� andtank, r) maximum ground water elevation in s) plan area sey„-age disposal system must be prepared by a Professional Mh eer or other professional authorized by law to prepare such plans S tic Tanks ,a) capac t es- 50% of flow access, pumping water tables tees, depth of tees, b) cleanout C) lot from cellar wall or inground swimmingpool. d) �5, from subsurface drains 10.2. Distribution Boxes - 10.4 (a) slope greater 0.08 b sump ouosiiriaye Desi Ch�k List Pae2' . LWT Pita Leaching Pits are preferred where the installation is possible Reg 11.2 11.4 a) calculations of leas area- mLnimwm 500 eq ft b) sPacing �g 11.10 c) surface drainage 2%11.11 d) cover material e 2 'a2 tx4n splash pad f tee at elbow g no bands in pipe from d -box to pipe teg 15.1Leac4in Fields a no g eater.tHE 20 minutes/inch b 15.4 area-minimrm 900 aq ft 15.8 c construction of field d) 3.7 surface drainage 2 % e) 201 from cellar -wall or inground svimming Pool � 1-1t.1 hin nrenches Leac-- 3-43 b' a spacin ons o eaching area-mi.n 500 sq ft g-4 ft min 6 ft with �6 : reserve reserbetinen c dimensions 14.6 . d) construction 214.10 a stone f surface drainage 2% Douahm Slo e - a s opo Y x = to be shown b Y/x Z 150 (to be shown 9.1 a) approval _ 9'6 b) stand-by Power CA C C C C C C C C C C C O O MASSACHUSETTS FIRE INCIDENT REPORT DEPARTMENT OF PUBLIC SAFETY OFFICE OF THE STATE FIRE MARSHAL 1010 Commonwealth Avenue Boston, Massachusetts 02215 Massachusetts MMMM Fire Incident Reporting ■ONA System 10 FDID# � Department n Revised JIFORM Report / &6- %��Q(%�%L P-32 Incident # .- ' %ba If exposure Fire only: DATE /0: �~�`- Da Of 1 Sun 2 Mon 3 Tue Alarrti Time Arrival TnService Week 4 Wed 5 Thu 6 Fri 7 Sat u�� �Z Z373 Z O D 11 f.J Structure fire 17 ❑ Outside spill with fire SEE MANUAL 13 [l Vehicle lire 18 ❑Other fires not classified FOR OTHER 2 Z 1 Extinguishment 5❑ Standby MUTUAL AID QD 14 O Brush, grass, leaves 47 (7 Chemical spill CALLS �j Y 2 ❑ Rescue or Assistance 6 ❑Salvage 3 ❑Investigation 1 1 Recd D 0 F- U. 15 n Trash, rubbish 44 ❑ Power line down ;1 7 16 Fl Explosion. No fire V Q Q f' only 7 F1 Ambulance 4 ❑ Remove Hazard 8 ❑ Fill in. Move up 21 Given N after 45 ❑ Arcing electric equipment N A FIXED PROPERTY USE (Occupancy) IGNITION FACTOR AL CORRECT ADDRESS (Up to maxlrr lm of 21 characters) ZIP CODE CENSUS TRAC t Z. 11 OCCUPANT NAME (LAST FIRST, Mq TELEPHONE ROOM or APT. It p 12 OWNER NAME : ;, (LAST; FIRST, MI) ADDRESS , TELEPHONE 13 METHOD OF ALARM 1 Telephone direct �'. CO. INSPECTION DISTRICT NO. O RESPONDED FIRE SERVICE PERSONNEL a NO. ENGINES RESPONDED NO. AERIAL APPARATUS RESPONDED 2 Municipal alarm system a 3 Private alarm system SHIFT ,,,� _ HAZARDOUS MATERIAL PRESENT? NO. TANKERS NO. OTHER VEHICLES RESPONDED RESPONDED YES ❑ NO ❑ 4 Radio 5 verbal 6 No alarm recd. 7 Tie -line (911) 8 Voice signal municipal alarm SUBSTANCE -- - NO. ALARMS signal USE FP 33 9 Not classified above /f FOR ALL 0 Undetermined or not reported Special Equipment Used? CASUALTIES 20 FIRE SERVICE NUMBER OF INJURIEES FATALITIEES OF NUMBEROF INJJURIEES N AMAL BIOS RESCUES _ OTHER MOBILE PROPERTY TYPE VEHICLE STOLEN? Yes ❑ No ❑ 11 AUTO, VAN 22 TRUCK UNDER 1 TON ESTIMATED TOTAL Insurance Co. 12 BUS 41 BOAT, UNDER 65' DOLLAR LOSS 13 MOTORCYCLE 21 TRUCK OVER 1 TON 08 NONE Total Insurance $ Claim Paid $ 30 YEAR MAKE MODEL COLOR LICENSE N0. VIN# i 40 EQUIPMENT INVOLVED YEAR MAKE MODEL SERIAL NO. IF GNITION br NZe;fr-, ff7T - Tiacv -- - COMPLEX ED AREA OF ORIGIN I EQUIPMENT INVOLVED IN IGNITION FORM OF HEAT IGNITION MATERIAL IGNITED FORM TYPE METHOD OF EXTINGUISHMENT 1 '1 Self LEVEL OF FIRE ORIGIN 1 ❑ Grade level to 9 ft. 2 ❑ 10 to 19 feet Number of Stories 1 F11 story 2 F1 2 CONSTRUCTION TYPE 1 f7 Fire resistive extin uished g 2 [1 Make shift aids 3 C1 20 to 29 feet stor Y 3 ❑ 3 to 4 stories 2 17 Heavy timber 3 n Protected noncombustible 3 1-1 Portable extinguisher 4 1 Automatic ext. system 5 (� Pre -connect hosetank only 6 ❑ Pre -connect hose. hydrant draft standpipe 4 [1 30 to 49 feet 5 [] 50 to 70 feet 6 f1 Over 70 feet 1777771 7 ❑ Objects in flight 4 [-1 5 to 6 stories 5 f-1 7 to 12 stories 6 ❑ 13 to 24 stories 7 ❑ 25 to 49 stories 4 F1 Unprotected noncombustible 5 1 1 Protected ordinary 61-1 Unprotected ordinary 7 n Protected wood frame 7 ❑ Hand -laid hose, hydrant draft standpipe 8 [ 1 Master stream device 8 CI Below ground level 9 n Not classified above 8 ❑ 50 stories or more -H� 8 0 Unprotected wood frame 9 f] Not classified above 0 CI Undetermined 0 1-1 Undetermined or not reported EXTENT OF DAMAGE Flame Smoke DETECTOR PERFORMANCE SPRINKLER PERFORMANCE 1 Confined to the object of room 2 Confined to part of room or area of origin 3 Confined to room of origin 4 Confined to the fire -rated comp. of origin © 1 (7 Det. in room or space of fire origin—oper. 2 El Det. not in rm. or space of fire origin—oper. 3 EI Det, in rm. or space of origin—no oper. 4 ❑ Det. not in rm. or space 1 fl Equipment operated 2 FI Equipment should have operated - did not 5 Confined to floor of origin 6 Confined to structure of origin 7 Extended beyond structure of origin of origin—no oper. 5 ❑ Det. in rm. or space of fire origin but fire too small to oper. 9 ❑ Not classified above 3 Fl Equipment pre. but fire too small to oper. 9 ( I Not classified above 0 FI Undetermined or not reported 9 No damage of this type (N,A) 0 ❑ Undetermined or not reportedED 8 ❑ No detectors present (N/A) 8 [l No equipment present IN A) IFS SPREAD BEYOND ROOM MATERIAL GENERATING MOST SMOKE FORM TYPE OF ORIGIN Co U(„_ - cleat"', AVENUE OF SMOKE TRAVEL 7 [_1 Utility opening in floor El Air handling duct 4 F] Stairwell 9 (-1 Not classified above WEATHER �}2 C7 Corridor 5 ❑ Opening in construction 0 ❑ Undetermined or not reported 3 ❑ Elevator shaft 6 C7 Utility opening in wall B ❑ No avenue of smoke travel IN A) CONDITIONS Entries contained in this report are intended for the sole use of the State Fire Marshal. Estimations and evaluations _ _ __ _ made herein represent "most likely" and "most probable" MEMBER MAKIN -ER and effect. Any representation as to the validity or DATE accuracy of reported conditions outside the State Fire jay Marshal's office, is neither intended nor implied. FIRE MARSHAL F.M. 1 ' Yes 2 ; No _ 11[11 =rMn r lvirnii %_Nnnviv wry: b IAlt f -I tMARSHAL gage 3- SOP CHECKLIST FOR CARBON MONOXIDE Location of Incident: r -V U /re'� Date of incident /2 QUICK CHECKLIST OF OCCUPANTS Headache yes no L-1 Fatigue yes no Nausea yes no� Dizziness yes no Confusion yes naL Are any members of the household feeling ill? yes no Do the residents feel better away from the house? yes no Since the detectors alarm went off, what have you done? Shut- off carbon monoxide sources yes no If yes which sources Let in fresh air? yes no If yes how did you let the air in How long did you let the air in PPM reading ambient outside the dwelling 0 Pf i'pl Highest PPM reading in the dwelling / ;P'PP' A Carbon monoxide detector present? yes no If yes list the number of detetors locations and make, and serial number of each below. 1. Ce 11 C. r 2 _ 1s7- v-) &ei2 -r — -a %'7 51i 2. 3. 4. o i( 2- ('"l°1 rT- i A) 91';2 Ll Which detector(s) by number above activated? / SOURCE CHECKLIST LOCATION PPM READING Chimney clogged flue, blocked opening (-' e //ale. Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace) 1. c 0i �''�'i 3. 2. 4. Gas Appliance (if Gas Company on Scene they can perform this check) (IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING) refrigerator stove vent over stove clothes dryer water heater (chimney pipe) furnace (gas,oil;leaking fluetchimney pipe barbacue grill (in eclosed or semi enclosed area Oil burner car garage Entranceway from garage to house Name of individual operating the CO monitor Person completing the Checklist /1 6111n" -y' •.A._ Wilasm F. Wild Goaamor Argeo Paul Celluocl LL Gawrnor Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental } iow BOA. NORTH A! 1D0\/EFi% Tq .� - — , Protection - �-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Trudy Coxa Secret" David B. Struhs Gomn111111ioner _ Property Address: ZD Date of Inspection: P ff L� B r / i /�P� Address of Owner. S a �+ (It different) Name of Inspector � �e S, Company Name, Address and Telephone Number. 30 �)r-! iv v -r rS ' /CjA CERTIFICATION STATEMENT ? Y- �a o! I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XPasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: . .. Date: (� G f .. � / �� 19.6 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: - I have not found any information which indicates that the systemviolates any f the faihue criteria as defined in 310 CMR 15. Any failure criteria not evaluated are indicated below. 303. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the inspection.replacement or repair, pasta Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) /VD The septic tank is metal, cracked structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winner Street a Boston, Massachusetts 02108 a FAX (617) SWI049 a Telephone (617) 292.SS00 0 Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: Z S a w µ: ((� No e Y 4/ �l/� !4. Owner. Date of Inspection: t L 1 B] SYSTEM CONDITIONALLY PASSES (continued) Ad _ Sewage backup or breakout or hugh gat i mate* tet,.., n.�t in +t,c a;.►.ati.,.r his due to broken or obstructed pips(s) �� �� r ! or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced N The SyStem required PumPmg more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY Tft BOARD OF HEALTH: Conditions ewhich require further evaluation Board of Health in order to determine if the system is failing to protect the Public health, ety and the environment. \\ 1) SYSTEM WILL P UNLESS BOARD OF HEALTH�?E MANNER WHICH PROTECT THE PUBLIC HEA', Cesspool or privy ' within 50 feet of a surface water Cesspool or privy is ' 50 feet of a bordering veg tMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A AND SAFETY AND THE ENVIRONMENT: or a salt marsh. Z) SYSTEM WILL FAIL UNLESS BOARD OF HEALTH (AND LIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE Sr. S FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil rphon surface water supply. The system has a septic tank and soil abso ion The system has a septic tank' and soil abso The system h:,2 a aeptic tank gmd soil absorption supply well, unless a well water analysis for colif from pollution from that facility and the presen 3) OTHER system and is within \00 feet to a surface water supply or tributary to a system and is within a I of a public water supply well. system and is within 50 f of a private water supply well. m and is less than I00 f but 50 feet or more from a private water bacteria and volatile o . w compounds indicates that the well is free ce of onia nitrogen and citrate is equal to or less than 6 ppm. (revised 11/03/95) 2 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 p S Q w m: // &L/ /Uo r f-11 Owner. u r S« r << r L ({ C► �� E.J Date of Inspection: { D) SYSTEM FAIL: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMI; 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in cility or system component due to overloaded or clogged SAS or cesspool. Discharge or ponding of a ent to the surface of the ground or surface waters due to an overloaded orc1ogged SAS or Static liquid level in the distribu n bo: above outlet invert due to overloaded or clogged SAS or cesspool. Liquid depth in cesspool is lea than below invert or available vo is less than 1/2 day flow. — Required pumping more than 4 times in a last year NOT due to clogged obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, 1 or privy is below the high dwater elevation. — Any portion of a cesspool or privy is within 100 f of a surface water supply or to a surface water supply. Any portion of a cesspool or privy is within a Zone I of public well. Any portion of a cesspool or privy is within 50 feet of a p ' water supply well. Any portion of a cesspool or privy is Ins than 100 feet but gree 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analysed to ptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and to nitrogen. El LARGE SYSTEM FAILS: The folio ' criteria apply to large systems in addition to the criteria above: The system se facility with a design flow of 10,000 gpd or ter (Large System) and the system is a significant threat to public health and safety environment because one or more of following conditions eaist: the system is 00 feet of a surface drinking water su ly the system is within 200 f f a tributary to a surface drinking ter supply the system is located in a nitrogen ve area (Interim Wellhead P Area (IWPA) or a mapped Zane II of a public water supply well) The owner or operator of any such system shall bring the system facility into full compliance with groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regio office of the Department for Anther informatics. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST nperty Addre D� O S-R.c✓ m : Y '\�d �o r r✓ � J fi E Owner. --t- Date of Inspection:f Check if the following have been done: V Pumping information was requested of the owner, occupant, and Boatel of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. 2 The facility or dwelling was inspected for signs of sewage back-up. L/ The system does not receive non -sanitary or industrial waste flow ZThe site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffies or I %tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of seam. V Ths size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. ZThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: :!- p –�cc. ��ce,' �f %is, tAco 6,-f Owner. /5 o t l. -- 4 C C 1. Date of Inspection: SIl", �' 2 ` / ��f(a RESIDENTIAL Design flow: ns Number of bedrooms: Number of current residents Garbage grinder (yes or no): Laundry connected to system (yes or no):�-S Seasonal use (yes or no): -/D Water meter readings, if available: 'Q� Lest date of occupancy: s� A COMMERCIAL/INDUSTRIAU TYPq of establishment: FLOW CONDITIONS c/ G,%a; i a C P Grease triresent: (yes or no)_ Industrial Waite.,Holding Tank present: (yes or no)_ to the Title 5 system: (yea or Water meter readings, ve ilable: Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: I System pumped as part of inspection: (yes or no) S 04Ati u n tY If yes, volume pumped: i s D O mon Reason for pumping o rI� o n t. --Y././ .f rJa �a ,c �E �° o y. r/'. SYSTEM Septic tanWdistrbution boysoil absorption system Singls cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (esplain) AP ROXIMATE AGE of all components, date installed (if known) and source of information: 46(9 Ace?a'S � okS�r�...<.�- �SS�.:.Q� %'23-x, 1ywt• Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �'S a i K c+ / /!%r 7%, 4" o c 6 '— Owner. r• r ,! L �C l (` r : �r-G ; Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: l b ,� Material of oonatruction: concrete _metal _FRP _other(ezplam) Dimensions: /49,5 w r 1 t. X S. S ' D��d Sludge depth 3 „ + r b Distance fiom top of oh=dge to bottom of outlet tee or battle: Scum thiclmm : < Z'r 4 �o fop from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler -- Comments: (recommendation for pumpmgrconditig n of inkft and outlet or baffles, de,* of liqujd level in re tion to outlet invert, structural evidence of leakage, etc.) �o r' c9S W r'& ! efr` N god d �l - 4 1'r'c � dA0K'/.' 4.i" or. c Get ME TRAP:_ (locate - on site plan) Depth below rade: Material of n: _concrete _metal _F other(explain) Dimensions: Salm thickness: Distance from top of scum to top o tee or battle: Distance from bottom of scum to bottom outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and tees or baffles, depth of liquid level lation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: • - O S� a I l lZ Owner. &. r ,(, r c. d Date of Inspection: TIGHT OR HOLDING TANK_ (locate site plan) Depth below Material of oonit�uction• _concrete _metal L,] RP _other(esplain) Capacity: sallona Design flow: aallons/da Alarm level: Comments: (condition of inlet tee, condition of alarm and floa , etc.) DISTRIBUTION Box (locate on site plan) Depth of liquid level above outlet invert: /✓o Comments: (note if level and distribution is equal, dente of solids carryover, evidence of leakage in or out of bas, etc.) �^ #.,P it i D P ' k, r rs j)I-At PUMP C BER:_ (locate on site p ) Pumps in worldag order: or no) Comments: (note condition of pump chamber, muht, and appurtenances, (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYS7MM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: .Z� .Sa.J Al %�( x/') Ar'j0 0 We r Owner.?tyre.. G Date of Inspeoton: '�'4jY7L SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if poml)le; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: b= ISO ching pits, number._ leaching chambers, number:_ iseching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 2S " >,"f/0 �` • J overflow cesspool, number: eats: (note condition soil signs of 40 It POI i _ .r _ . . CESSROOLS: _ (locate onsite plan) Number and on: Depth -top of liquid inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Material of construction: Indication of groundwater: inflow (cesspool must be pumped of inset Comments: (note condition of soil, signs of hydraulic failure, PRIVY: _ (locate on site plan) Material of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, Of ponding, edition of of ponding, condition of vegetation, etc.) (revised 11/03/95) g Dimensions: condition of vegetat o ; etc.) S 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIONr(oontinued) Property Adder o S ; l , ��� fh ,t. clv Date of I SKETCH OF SEWAGE DISPOSAL SYSTEM; inchide ties to at least two permanent references landmarks or benchmarks locate all welts within 100' DEPTH TO GROUNDWATER Depth to groundwater l0 feet �J / method f determination o; app /im tion: CI c vwg it o+ c� lJ O, d At > 701_ (revised 11/03/95) 9 tea, aw INSPECTION SUMMARY Property Address: 20 Sawmill Road, North Andover Owner: Barbara & Luke Griffin Date of Inspection: September 21, 1996 The in -ground sewage disposal system serving this property was observed in proper working condition at the time of this inspection. It may be noted also that the maintenance schedule of the system included annual pumping and, even though the system was designed for 1200 gallons per day, the average daily water use was approximated at 260 gallons per day. (Town Water Bills are available to verify these data.) Further, a review of the Board of health files shows favorable conditions for in -ground sewage disposal in this area. Please consider: six (6) inspections in the neighborhood since March of 1995 have not been observed failing to protect public heath or the environment; the gravely sand with a percolation rate of 7 minutes/inch is not uncommon in this area. Due to the liberal maintenance schedule, the 1500 gallon septic tank contained minimum levels of sludge and scum. As mentioned in the Report, the tank was observed in good physical condition and properly working. The field is built at a high point of the property, away from low lying, wet areas. Vegetation (the well manicured yard) provides no evidence of overuse or unequal use of the leaching field. The distribution box was excavated on three sides and showed no indication that it was not watertight or structurally unsound. A large boulder (greater than 4' in diameter) resting on top of the cover made removal of the cover unfeasible. My opinion is that removal of this boulder would disrupt the functioning of the system and, I decided not to proceed further with this evaluation. Naturally, this circumstance did not allow for the assessment of the liquid level in the d -box.. Upon referring to page 1 of the DEP's Guidances the Inspection oSubsu ace Sewage Disposal S stems (revised 11/03/95) which reads, "The goal of the inspection is to provide sufficient information to make a determination as to whether or not the system is adequate to protect public health and the environment.... The inspection must avoid disruption of the functioning of the system and should be conducted to minimize disruption of the site in general.", it is my opinion that I cannot FAIL or CONDITIONALLY PASS the system because none of the criteria listed in 310 CMR 15.303 have been met. However, after consulting with you at your office on October 3, 1996, I will concede your point that the Local Approving Authority should evaluate all "Not Determined" entries on the inspection form and make a final decision as to whether further investigation is required. In summary, my inspection showed no evidence of this system failing to protect public health or the environment at the time of inspection. If you or your Board decides further evaluation is required which will cause the owner to open the distribution box, please contact me in writing at your earliest convenience. I look forward to confirming your opinion by telephone later this week. END OF REPORT 1 Wllllam F. Weld Go►vmor Argeo Paul Celiuccl U. Govwmor Commonwealth of Massachusetts Executive Office of Environmental Affairs ®apartment of Environmental Protection TOWNOF NORTH .......NDOVER/ BOARD OF HSALTH cn-i- Z 4 1996 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION s.cntaiy David S. Struhs Commmskx er PropertyAddresa: LD Saw�ti; d �t%�f-4./- Address of Owner. S a Date of Inspection: P,� �" ?�� i/���� (If different) Name of Inspector- Company nspectorCompany Name, Address and -Telephone Number. _30 Wus 4� J�`� ���Rll%frS /-I CERTIFICATION STATEMENT -"/_ �., 0 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspectoz's Signature: G�/I QS, Date: �� 6 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al :SYSTE3vi PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B1 SYSTEM CONDITIONALLY PASSES: 7C One or more system components need to be replaced or repaired. The system upon completion of the replacement or repair, passes inspection. p Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) 124 The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 a Telephone (617) 292.5500 A %j Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /CERTIFICATION (oonti/n_ued) Property Address; S Q w �N : C Nc r �' ` /� p�/ Co�(/•Q !/ Owner. Date of Inspection: � t B] SYSTEM CONDITIONALLY PASSES ((continued) Pt t _ Sewage backup or breakout or high static water learel..obse��the , M oa bz is due to broken or obstructed pipe(s) Pt� f, M or due to a broken, settled or uneven distribution bo:. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution bo: is levelled or replaced AlpThe system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions elitt which require further evaluation by'the Board of Health in order to determine if the system is failing to protect the public health,Xanenvironment. 1) SYSTEM WIESS BOARD OF HEALTH ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesswithin 50 feet of a surface water Cesspool or privy is hin 50 feet of a bordering vegeta wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYS S FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil rption system and is within 00 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil abso ion system and is within a Zo e I of a public water supply well. The system has a septic tank' and soil absorpti system and is within 50 f, of a private water supply well. The system has a septic tank and soil absorption m and is less than 100 f but 50 feet or more from a private water supply well, unless a wa1 aster analysis for rolifo baeters and volsiile orgsni mpounda indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PART A CERTIFICATION (continued) Property A ddress: 2� S/ccw/�K : ii �t c c/clavpv- Ownea Date of Inspection:�I D] SYSTEM FAILS: 77 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage is acility or system component due to an overloaded or clogged SAS or cesspool. 't Discharge or ponding of a \ent the surface of the groundor surface waters due to an overloaded or clogged SAS or cesspool.Static liquid level in the disn box above outlet invert due too an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than " below invert or available volumis less than L2 day flow. Required pumping more than 4 times in he last year NOT due to clogged br obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, ce*M"I or privy is below the high gr Any portion of a cesspool or privy is within 100 fe4kof a surface water supply or Any portion of a cesspool or privy is within a Zone I Any portion of a cesspool or privy is within 50 feet of a well. water supply well. Any portion of a cesspool or privy is less than 100 feet but greate han 50 feel from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to ptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and ni to nitrogen. elevation. to a surface water supply. El LARGE SYSTEM FAILS: The follo' criteria apply to large systems in addition too he criteria above: The system se facility with a design flow of 13,000 gpd\-r ter (Large System) and the m is a significant t yste system tgnrfi brant to public health and safety environment because one or more of tollowing conditions exist: the system is withw400 feet of a surface drinking water supply the system is within 200f f a tributary to a surface drinking ter supply the system is located in a nitrogen itive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone H of a public water supply well) The owner or operator of any such system shall bring the system and��f,acility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regio2�a1 office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Y ! Property Address: 2 d S a Ga to : , Nc) r s`�i F✓ moi:. t� '� Owner. f.f Date of Inspection: / Check if the following have been done: ZPumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _L/As built plans have been obtained and examined. Note if they are not available with N/A 1 The facility or dwelling was inspected for signs of sewage back-up. VThe system does not receive non -sanitary or industrial waste flow V/The site was inspected for signs of breakout. L/ All system components, excluding the Soil Absorption System, have been located on the site. v The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ba®es or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. '%! The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. /The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address ` -,tr .e kt (' f /r r► �C`. v'� Owner. 1>at-��rc� f �.� G^s•,,, Date of Inspection:� RESIDENTIAL Design flo'0¢all ns Number of bedrooms: Number of current residents: Garbage grinder (pet or no):� Laundry connected to system (yes or no):�S Seasonal use (yes or no):_/VD Water meter readings, if available: Ste— Inst date of occupancy:S%!J COMMERCIALANDUSTRIAL: TyKof establishment: _,gallons/day FLOW CONDITIONS Grease tra resent: (yes or no)_ Industrial W Holding Tank present: (yes or no)_ Non -sanitary w harged to the Title 5 system: (yes or Water meter readings, vailable: _ Lest date of occupancyN OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: j`` ,£t �I r ; ` / �, S �� tI G` r ✓ �,,v u n System pumped as part of inspection: (yea or no)_Zf 4S �. If yes, volume pumped: / Y O O eallons Reason for pumping: Ta rll. o At ,0, 41 -1 dA 1u ,c 7/ C° a y. r j/i ? z B t' .M1,-Q�l T G -7eP r✓ r i TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) AP ROXIMATE AGE of all components, date installed (if ]mown) and source of information: Sewage odors detected when arriving at the site: (yes or no)_!'/ (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (oontinued) Property Address: ? SG„� cc r O/ K /J�r ��r ✓-N.�U-� Owner. Date of Inspection: �, r SEPTIC TANK_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: 10,.5- X S. Sl iv 1',14 )e Sludge depth: 3 " Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: Distance' from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Z Comments: (recommendation for pumpingco tion of inl t and outlet taes or bathes, dep h of liqi�'d level in relation to outlet invert, structural integrity, evidence of kakage, etc.)) T., w is B�'any roc 8-i" e.'� c+� +- + ��, e( V r.t itA -4,1 A4 A 1,P 4-- 'A't + A F* d> 'fe r!!- % iT TRAP: site plan)_ Depth belowgrade: Material of co"ion: _concrete _metal Scum thickness: Distance from top of scum to to�oet e or baffle: Distance from bottom of scum toutlet tee or baffle: Comments: \ (recommendation for pumping, condition of inlet and evidence of leakage, etc.) (revised 11/03/95) tees or bathes, depth of liquid level inelation to outlet invert, structural integrity, 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y SYSTEM INFORMATION (continued) Property Address: + w i`1 ;' Owner.., Date of Inspection:�� TIGHT OR HOLDING TANK_ (locate=below: ) Depth�� Material of constriction: _concrete _metal _FRP _other(ezplain) Capacity: senors _"\ Design flow: Gallons/da Alarm level: Comments: (condition of inlet tee, condition of alarm and floa-gwitches, etc.) DISTRIBUTION BOX- (locate OX(locate on site plan) Depth of liquid level above outlet invert: Comments: (note if levelanA distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) S A, P 4- c ..• .► t O cc An yc' 4% G. G . t� w M bC tat- V PUMP C BER:_ (locate on site p ) Pumps in working order: or no) Comments: (note condition of pump chamber, conditiof pumps and appurtenances, etc. (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO/RMATION (continued) Property Addresxf .zo oa Vii: K �r Ft 1�p,a.0 c? e Owner. � 4 -- Date - Date of Inspection: S'A�.i./� SOIL ABSORPTION SYSTEM (SAS): — (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: B leaching fields, number, dimensions: overflow cesspool, number: Co eats: (note condition,�oof soil, signs of hydraulic failure level of ponding, condition of vegetation,etc.) � - 4,L y-- to d r, fL" NUUC.- P�t�o � '0 4 jp" s� 0�- A, .-fir . A.' r �r are, Of - /./.2 -1 � .P _lD --f- a .- . C._ .&,. .A w.A.r OF (locate onsite plan) Number and coii5figuuration: Depth -top of liquid inlet invert: Depth of solids layer: Depth of scum layer- Dimensions ayerDimensions of cesspool: Materials of construction: Indication of groundwater- inflow roundwaterinflow (cesspool must be pumpedftpart of Comments: (note condition of soil, signs of hydraulic failure, PRIVY: _ (locate on site plan) Materials of construction: \. Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 condition of vegetation', Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMAy�TION�(continued) Property Address: D Scams M l /� `�✓fir /7N Cad U'�� . Owner.6r" Date of Inspection: ! SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: i l0 feet . method f determination or app tion GJ��� or>- (revised 11/03/95) 9 INSPECTION SUMMARY Property Address: 20 Sawmill Road, North Andover Owner: Barbara & Luke Griffin Date of Inspection: September 21, 1996 The in -ground sewage disposal system serving this property was observed in proper working condition at the time of this inspection. It may be noted also that the maintenance schedule of the system included annual pumping and, even though the system was designed for 1200 gallons per day, the average daily water use was approximated at 260 gallons per day. (Town Water Bills are available to verify these data.) Further, a review of the Board of health files shows favorable conditions for in -ground sewage disposal in this area. Please consider: six (6) inspections in the neighborhood since March of 1995 have not been observed failing to protect public heath or the environment; the gravely sand with a percolation rate of 7 minutes/inch is not uncommon in this area. Due to the liberal maintenance schedule, the 1500 gallon septic tank contained minimum levels of sludge and scum. As mentioned in the Repo? -t, the tank was observed in good physical condition and properly working. The field is built at a high point of the property, away from low lying, wet areas. Vegetation (the well manicured yard) provides no evidence of overuse or unequal use of the leaching field. The distribution box was excavated on three sides and showed no indication that it was not watertight or structurally unsound. A large boulder (greater than 4' in diameter) resting on top of the cover made removal of the cover unfeasible. My opinion is that removal of this boulder would disrupt the functioning of the system and, I decided not to proceed further with this evaluation. Naturally, this circumstance did not allow for the assessment of the liquid level in the d -box.. Upon referring to page 1 of the DEP's Guidance for the Inspection ofSubsu ace Sewage Disposal S sS ty ems (revised 11/03/95) which reads, "The goal of the inspection is to provide sufficient information to make a detern nation as to whether or not the system is adequate to protect public health and the environment.... The inspection must avoid disruption of the functioning of the system and should be conducted to minimize disruption of the site in general.", it is my opinion that I cannot FAIL or CONDITIONALLY PASS the system because none of the criteria listed in 310 CIvIR 15.303 have been met. However, after consulting with you at your office on October 3, 1996, I will concede your point that the Local Approving Authority should evaluate all "Not Determined" entries on the inspection form and make a final decision as to whether further investigation is required. In summary, my inspection showed no evidence of this system failing to protect public health or the environment at the time of inspection. If you or your Board decides further evaluation is required which will cause the owner to open the distribution box, please contact me in writing at your earliest convenience. I look forward to confirming your opinion by telephone later this week. END OF REPORT t—t8.-1S' o N O Jv ti Z4 N O iti t3L LiI i-1LILitJk �i .�cJiCL Ci iJi iiG�Li.LI z4Zit Amuse - ,,2ly -!O in S+� _Z'+f=ait .__-,`L,`i - -='-k =------ � .�L'.i.L. si:-i 's.:i : vziii;'r b•;y �i'ir .; z a, -r.� The, , i1urrnse of F.<iiu y '1<i4: 'ii:, is o ,as.am-re that fie ili d S-ubii, 7T4, -C JYfr 2l!al�¢ Pr -s:_ _.:.. ._tt Stle_,f.T1 bull on �C4`C. �� 0 til tai! on r -m ! _ i. I, in adr]ttior. I.I int (vr?l'l1(l nm 1=an_e-fP IV S -,.t PartCi r ��"- � (� - �iV?Ctn - _ t y - I. UCit7LG�iiDe i Ii�i�tiJ �.ii IiLij TGii LiVi2 Tiv �,3 i(Ulli ilii i.0 i.i V1 LSSG 3p'3LGIII. � iilu.L LiIIIG� UCliiiiiGi ZJIi3C;GCi UII top fi{+he dist-lbul o h:s�. mn�� A ltn..nS c,hie o i'?.�' c-- Thu � ! L: ��'^.` ��J�� F �� 1 �+.�'�t.L'r�i[�. U. -U.. A_ - moi' i- ug t;iC_ i[3s i,i to diitJW ti tZ7iTIL7ieL ili-, 7 :(,;i1UII Oy" -,ri i,L i.it TTIC.,riiii, iIU'ii,I:i 74 Lri zii..i4[ r ,iiiz,{Z, LFI Luz (;L-i1C5}R LR. i Ik -7. iieZi iiS'I MISY'YL iia iJ wti Li'awL i;:3 6,iwp;,W "Cl v-Ii.0 il-v7.a' LEVZ _,," a I.lb.3 (s-Lis3iCel %.T Y.7G iid iV Li iE.3�Gl LGd iiFd Z G(ii db L. Idl.d �i� za l thP'�,'��sk ;- �� cmar'� tae dl -box. O `t"tlesfin�' Sa -. 7_lask vv s To rn� 4. On do Sia 1199-1 _ s iiL5t3 F (3 i+i cs-%1tl?S. ,-jy �i[l ftf Tlclti F :',t3Yt�4 tii3 fids t i l+'L tai 1e Ll- anX v.timcaa ii er- no cL'Li.iGZli. iiiiG L`aL.[iv:'. ILLLCi i1L [J'CiC iJL LILG i?iJA.^+ 'Mis F3 s i.^, the Vi i .' dh-n om *0 0— _Q iCk_Tl r{� T}j e`lp5. - _tli MlE.,i3i: L.rs =Q ul a 'k. W;RtT J�',LLifLg die, cat -stub .tion Line and appl- %zi Ci i nvW'-1 d WtAt e- i[, •.F`s'V Li iVi j'iJidL iii LLG v'.ZLLi 4ViL;.�L�iiii+iL iLjaZL i.iLLI� sailer ilisi'sLLl, i iLwAiL VL/IiiaiVi iilL l2 fiii a'Iar�avL uiL v.�viG.'iiI'viI:3 ii2 CIs TICICI LtS Peter i1T_ miTplidl, RIS!, V?,iJ4. Env JiJVi' Fir__ 111'at - Ix "ivillw asn_�i .i L w i iYiSYiii �IlLii( W,C3V _.CHIS -16%_ IAIN Ion F.1NNd GwAm r Argeo Paul Cellucci LL GWAMCX Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Trudy Cox* David B. Struhs Gortwr�faeiorwr PropertyAddress: Data of Iaspe&..lon:r f!� Gj L r 2 / ,/9�G. Address of Owner.S a M (It different) Name of Inspector - Company Name, Address and Telephone Number. 30 W.s �r�RlULrj � �i1 �/p23 CERTIFICATION STATEMENT 5a8/ y- -Soo/ I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date-- The ate: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shard system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or'D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any f the failure criteria as defined in 310 CMR 15.303. Any failure Criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or -repair, pastes t*� `Indicate yet, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined /VD The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or e25ltratio or tank failure is why ) imminent. The system will pass inspection if the existing septic tank is replaced with a Fonformn' ing septic tank as approved by the Board of Health. pp (revised 11/03/95) On* AntOr Street * Boston, Massachusetts 02108 * FAX (617) MG -1049 * Telephone (617) 292 -UN 0 Printed an Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ( / / CERTIFICATION (oonti/nued) Property Addresx Owner: V Date of Inspection: SfLf / /y�(A BISYSTEMCONDITIONALLY PASSES (continued) �OT _ Sewage backup or breakout or high static ZZWr tocol 9hjgMW h. dye to broken or obstructed pipNs) Pt ( or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of J Health): broken pipe(s) are replaced obstruction is removed ' / distribution box is levelled or replaced N g The system required Pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY TIFF BOARD OF HEALTH: Conditions ' which require further evaluation by he Board of Health in order to determine if the system is failing to protect the public health, ety and the environment. 1) SYSTEM WILL P UNLESS BOARD OF HEALTH ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH PROTECT THE PUBLIC H AND SAFETY AND THE ENVIRONMENT: Cesspool or privy 4T" 50 feet of a surface water Cesspool or privy is 50 feet of a bordering vegeta wetland or a salt marsh. !) SYSTEM WILL FAIL UNLESS BOARD OF HEALTH (AND LIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYS 3 FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil rption system and is within 00 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil abso ion system and is within a I of a public water supply well. The system has a septic tank and soil &boo system and is within 50 f of a private water supply well. Tree system has a septic tank and soil.; m and is leas than 100 f but 50 feet or more from a private water supply well, unless a well water analysis for colif�bacteria and volatile compounds indicates that the well is fine from pollution from that facility gad the presence nitrogen and nitrate is equal to or less than 6 ppm N S) OTHER i - (revised 11/03/95) Z 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM• INSPECTION FORM d PART A ,l�CERTIFICATION (oontinued) PeopertyAddeess: 2a Sctwm i� /�� /mor {-r 4,Jd1dvpi,— Owner: u r a Y Y Date of Inspection: D) SYSTEM FAIL: l I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.903. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corrsct the failure. — Back<up of sewage in cility or system component due to overloaded or clogged SAS or cesspool. — Discharge or ponding of nt to the surface of the ground surface waters due to an overloaded or clogged SAS or cesspool. — Static liquid level in the distribut n box above outlet invert due to overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is lens than " below invert or available vo is less than 112 day flow. — Required pumping more than 4 times in a last year NOT due to clogged obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, 1 or privy is below the high water elevation. Any portion of a cesspool or privy is within 100 f of a surface water supply or to a Surface water supply. Any portion of a cesspool or privy is within a Zone I of public well. Any portion of a cesspool or privy is within 50 feet of a p ' water supply well. Any portion of a cesspool or privy is less than 100 feet but 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to ptable, attach copy of well water analysis for Coliform bacteria, volatile organic compounds, ammonia nitrogen and te nitrogen. E) LARGE SYSTEM FAILS: The fo criteria apply to large systems in addition to criteria above: The system se facility with a design flow of 10,000 gpd or ter (barge System) and the system is a significant threat to public health and safety environment because one or more of following conditions eaiet: — is feet of a surface drinking water su — the system is within 200 f a tributary to a surface drinking ter supply — the system is located in a nitrogen area (Interim Wellhead P Area (IWPA) or a mapped t~. water Supply well) Zone II d a public The owner or operator of any such system shall bring the system facility into bill compliance with groundwater treatment requirements of 314 CMR 5.00 and 6.00. Please consult the local regio office of the prom is Department for llrrther information., (revised 11/03/95) 3 ,.r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PlapwtyAddrew 10 S QAa pt : (( �C 1 / c ' f-4 Xi✓ Ja a Q 1 Owner. � u1. <« <- a { G K k< 4" 1 Al Dale of Inspection: Cheek if the following have been done: ZPumping information was requested of the owner, occupant, and Board of Health. v None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. . lAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. (,�jThe system does not receive non -sanitary or industrial waste flow V The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. V The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or I /teas, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. ZThe facility owner (and occupants, if different from owner) were provided with information on the �° P proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: :1. D .sem,, m,' /l )� tf- . x Owner, 6-r6..r-. f G, * Date of inspsetion: �V t ' >-/ ! / EO ZNTIA L- ao Number of bedrooms: Number of current raeidents Garbage grinder (yes or no): Laundry connected to system (yes or no): -Au Seasonal use (yes or no): -,62 Water meter readings, if available: Last date of occupancy:s��� COMMERCIALANDUSTRIAU Z+De of establishment: Grease tri resent: (yes or no)_ Ind atrial W Holding Tank present: (yes or no Non -sanitary to the Title 5 system: (yes or Water meter readings, vailable: Last date of occupancy: N OTHER (Describe) Last date of occupancy: FLOW CONDITIONS GENERAL INFORMATION J PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)S If yes, volume pumped: /S 00 Qallons Reason for pumping: To AF o n 1"Y Le 7.e Cow- 6/,' �i tel i f ��% �� ` C 714 n/ K � TYPE SYSTEM t&Wlistribution box/soil absorption system Single cesspool Overflow cesspool pm'y Shared system (yes or no) (if yes, attach previous inspection records, if nay) t Other (explain) AITROXI.TE AGE otaoomponents, date installed (if known) and source of information: VN CarC+S �yy,�, a ,.. l A-�ej f Sewage odors detected when arriving at the site: (yes or no) trevised 11/03/95) tf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: X1 " � A,0(.0o Q Owner. �, r�. �; ') Date o! Inspection: c,� {• 1 / �� SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: �aonc:ete _aural _FRP _other(eiplaia) Dimenaons: _ 10,5 L � X S. S" w 1 t X Sludge depth: 3 " + Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 4 2 rr 4 q Distance from top of scum to top of outlet tee or baffle: ' Z Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, tli of inl and outlet tges or baffles, depjh of 1i 'd level in re tion to out invert, structuraltegrity, evidence of �8e, etc.) ry ((�c t r t► t d ' a d i s E TRAP:_ (lova on site plan) Depth below Material of co a: _concrete _metal _F other(e:plain) anmennons: Scum thickness: Distance from top of scum to top o flet tee or baffle: Distance Som bottom of scum to bottom outlet tee or baffle- -;;E : Comments: (recommendation for pumping, condition of inlet andtees or baffles, depth of liquid level lation to outlet invert, structural integrity, evidence of leakage, etc.) IN I r SUBSURFACE SEWAGE DISPOSAL SY87M INSPECTION FORM PART C 1' j� SYSTEM INFORMATION (oontinned) Property Address: o'A%/�(i �l 4Q I Owner: 84,r lAr a, + L d� k Q Gr6r,*�f lr i A' Date of Inspection: TIGHT OR HOLDING TANK_ (bcate site plan) Depth below Material of —concrete metal _ other(stpyin) Design flow: sallojda Alarm level: Comments: (condition of inlet tee, conditifloe , etc.) DISTRIBUTION BOX - ( (locate on site plan) Depth of liquid level above outlet invert: Comments: A (note if level and distn'bution is evidence of solids carryover, evidence of leakage into or out of box, etc.) '✓ W4S J .Q4ry i e/ Dc. 1 �l/�,c:� / s : i pow GC,ve / , 2, /� f / " PUMP ER. (locate on site p ) s Pumps in working order. or no) Comments: (note condition of pump umber, oonditio and appurtenances, 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address 2O �a,, ,N : P , No - j -A 14rbc p v e i� . Date of �- Inspso�tion: rc. SOM ABSORPTION SYSTEM (locate on site plan, if possible; s:cavation not required, but may be approximated by non -intrusive methods) U not determined to be present, arplain: Type: leaching pita, number:_ leaching chambers, number:,_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 2-5"' X V0 overflow cesspool, number: (locate own i plan) Number and Depth -top of liquid inlet invert: Depth of solids layer Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped of inspc Y Comments: (note condition of soil, Signs of hydraulic fail; e, PBIVY: _ 00eate on site plan) a Materials of construction: tion: Depth of solids: ' Comments: (note condition of soil, signs of hydraulic failure, n (revised 11/03/95) of ponding, condition of vegetation, etc.) 8 condition of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION/A ontinued) Property Addrem O -so") Owner: 6. r ,ljw a d6 sp eotao Date of Inn; SKETCH OF SEWAGE DISPOSAL SYSTEM: include tim to at hest two Permanent references landmarks or benchmarks beats all wells within 100' jids ,...�'� ,v DEPTH TO GROUNDWATER Depth to gramdwater il0' feet - insthoddetermiaa//tion p/r aPP / tion: rl YW `1 /ivl O W 09 d r<S i S 0 v l» 1% - o dr rorK /4 S sa.w NII a Q �-t v 4 ti ow V Arevised 11/03/95) 9 Y iz' INSPECTION SUMMARY Y Property Address: 20 Sawmill Road, North Andover Owner: Barbara & Luke Griffin Date of Inspection: September 21, 1996 The in -ground sewage disposal system serving this property was observed in proper working condition at the time of this inspection. It may be noted also that the maintenance schedule of the system included annual pumping and, even though the system was designed for 1200 gallons per day, the average daily water use was approximated at 260 gallons per day. (Town Water Bills are available to verify these data.) Further, a review of the Board of health files shows favorable conditions for in -ground sewage disposal in this area. Please consider: six (6) inspections in the neighborhood since March of 1995 have not been observed failing to protect public heath or the environment; the gravely sand with a percolation rate of 7 minutes/inch is not uncommon in this area. Due to the liberal maintenance schedule, the 1500 gallon septic tank contained minimum levels of sludge and scum. As mentioned in the Report, the tank was observed in good physical condition and properly working. The field is built at a high point of the property, away from low lying, wet areas. Vegetation (the well manicured yard) provides no evidence of overuse or unequal use of the leaching field. The distribution box was excavated on three sides and showed no indication that it was not watertight or structurally unsound. A large boulder (greater than 4' in diameter) resting on top of the cover made removal of the cover unfeasible. My opinion is that removal of this boulder would disrupt the functioning of the system and, I decided not to proceed further with this evaluation. Naturally, this circumstance did not allow for the assessment of the liquid level in the d -box.. Upon referring to page 1 of the DEP's Guidance dor the Inspection of ubsu ace Sewage Disposal S s terns (revised 11/03/95) which reads, "The goal of the inspection is to provide sufficient information to make a determination as to whether or not the system is adequate to protect public health and the environment.... The inspection must avoid disruption of the functioning of the system and should be conducted to minimize disruption of the site in general.", it is my opinion that I cannot FAIL or CONDITIONALLY PASS the system because none of the criteria listed in 310 CMR 15.303 have been met. However, after consulting with you at your office on October 3, 1996, I will concede your point that the Local Approving Authority should evaluate all "Not Determined" entries on the inspection form and make a final decision as to whether further investigation is required. In summary, my inspection showed no evidence of this system failing to protect public health or the environment at the time of inspection. If you or your Board decides further evaluation is required which will cause the owner to open the distribution box, please contact me in writing at your earliest convenience. I look forward to confirming ming your opinion by telephone later this week. END OF REPORT N't 1—j8.Z S .4 e 4S�3oco t5'� . . M` N RECEIVE® Commonwealth of Massac se is l PA City/Town of MAY 1 2006 System Pumping gCQr TOWN OF Nv^RTH DC Form 4 . HEALTH DEPART Important: Whan filung put forms on the computer, use only the tab key to move your cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the \ information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information I. System Locat-i'o P, (i AddressWPI (/'/��/�U 1� V Ci Y � City[Town 2. System Owner: Name state Zip Code Address (f different from location) city!! own z _ State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: [] ❑ Other (describe): Dace 2. Quantity Pumped: Gallo s Cesspool(s) 01�eptic Tank ❑ Tight Tank -4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: 7. t5fGmA-d0a 06103 If y9s, wat it deaned? ❑ Yes ❑ No t' 17'lo o Vehicle Licen Number , Company L� T System Pumping Record • Pape 1 of 1